Find out what other moms-to-be are asking. Join in the discussion with Henci Goer, whose expertise is determining what the research tells us best promotes safe, healthy birth. If you would like to contact Henci outside of the Ask Henci forum, send an email to Goersitemail@aol.com.

Hi, I am desprate to find some information. I will try to be brief.
I had my first child in '98 I was induced for preeclampsia and I
was also past 42 weeks by a few days. I ended up with a c/s. Five
years later during my preg. I tested positive for group B strep. I
went to the hospital leaking fluid and they decided to keep me. I
was a week or so past due. I was given time to see how things went
and after a few hours the doctors wanted to do a "soft induction"
with a prostaglandin gel. I continued to labor for about 15-20
hours. I was having a lot of pain in my hips and felt like I wanted
to maybe push, well I was still only 4cm. Now here, I think, was my
mistake, I asked for an epidural. I'd been in labor almost 30hours
and I just was so let down that I'd not really made any progress.
After having the epidural I fell asleep for a few hours and woke up
with pain in my abdomen. Only with contractions. I was feeling it
along my old scar and a popping feeling. Baby was doing well still
and no heavy bleeding. At this point they took me in for another
c/s. What I was told was I had ruptured, and not to become preg.
again. Also they thought the reason I was not dilating and the hip
pain was because my son was "star gazing" like with his head tipped
back I think. This was in a German hospital so I'm not sure of the
correct term. When I asked for more info they said my scar was open
all the way across and I'd torn into my cervix. They also said my
son was still in my uterus. I've since seen a high risk OB here and
he said that was dehiscence and I wold need another c/s around
38wks but could become preg. again and be followed by a regular
OB.
Now my question is, is it totally out of the question to have a
VBAC? I live in FL which is one of the worst states for VBAC right
now but I am willing to fight for it, I just need more information.
I can't find any studies that relate to my case. I also need to
"prove" it to my husband, who is very worried for me. He was told I
could have died after my son was born. Please Help me find
something. It is hard for a lay person to search when I don't know
where to even look.
Thank you,
Heather By: Heather

It sounds from your story like the scar gave way entirely even
though it didn’t do any harm to you or the baby. In such
cases, it is recommended that the woman plan a repeat cesarean. I
am not aware of any research on this point. I doubt that there
would be enough cases where women with scar rupture in a previous
labor after c/sec would be allowed to labor again to produce any.
Even so, it does seem just common sense that if the scar gave way
in one labor, it is likely to do so again. It should be your right
to refuse surgery under any circumstances, although that right is
being flouted in this country when it comes to women and repeat
cesarean surgery, but would it be wise for you to do so?

If you want to learn more about VBAC vs repeat c/sec, you cannot do
better than
VBAC or repeat cesarean?. Among other things, you will find
information on planning for a safer cesarean and a positive
cesarean birth experience.

Speaking of safer cesareans, scheduling a c/sec at 38 weeks
increases the chance of the baby having respiratory problems severe
enough to require admission to intensive care. At the very least,
you should wait until 39 wks, although even then, there is still an
increase in the rate of respiratory complications. But were I you,
I would want some evidence of increased risk of scar problems in
the final weeks of pregnancy before scheduling surgery at all
before your due date. Not every baby is “done”
according to the calendar. The onset of labor is still the best way
of determining this. It is possible, of course, to have the scar
open during pregnancy, but it is extremely rare and I don’t
know if there is any association with week of pregnancy. If the
concern is labor starting in the middle of the night, I suggest you
plan to have your baby in a hospital where there is no problem
setting up for a c/sec any time of the day or night. In fact, if
your ob calls ahead, they can be set up for you when you get
there.

As a side note, you are correct in your understanding of
“stargazing.” It means the baby’s head is tipped
back so that the baby is looking up. The problem can occur in
breech babies—babies who are head up instead of head
down—in which case they would be looking at the sky.

Thank you for the input. I did look at the site you recommended.
One section said if there was seperation of the scar that may not
be a reason to have a repeat c/section. Is my case somewhat
different since mine opened all the way along? I was also thinking
the use of a prostagiandin gel and pitocin really effected the
outcome of my labor. I have heard of a midwife in my area who does
homebirth VBAC. Would that be too risky?
Heather By: Heather

The recommendation differs for symptomatic scar separation, usually
called scar or uterine "rupture" and "dehiscence," meaning a window
opens in the scar. Since different caregivers described what
happened to you using both terms, and, in fact, you didn't
experience any alarming symptoms, it isn't clear which category you
fit into. You are also correct that prostaglandin gel and Pitocin
could have affected your uterine scar.

At this point, I think your best bet is to discuss your individual
case with a practitioner who encourages VBAC, although
unfortunately such a person is hard to find these days. Then if a
repeat cesarean is recommended, you will have a basis for trusting
the practitioner's judgment because you will know it isn't just
because he or she prefers repeat c/secs. If you connect with this
midwife, she should frankly discuss the potential harms as well as
benefits of planning a home VBAC if she is willing to attend you.
You need both sides in order to make an informed decision.

Please keep us posted on what you decide and how everything goes
for you.

Henci,
We are still TTC at this point, but, I have a question. You
mentioned in your post that the recomendation differs for rupture
and dehiscence. Can you point me to where I can read what they say?
I have been doing a lot of reading and joined an ican group
online, these things have helped me clear my mind so much. I have
will try to HBAC if I can find a provider. I felt so much stress
just thinking about going in to another hospital. However, if it is
recomened by a provider I trust(someone who supports VBAC and
normal birth) that I should plan another c/s I will give it serious
thought. I am also wondering if mulitple induction drugs are given
do the risks that go along with them go up accordingly. What I mean
is say a prostaglandin gel increases rupture risk by 4%- don't have
numbers in front of me- and pit also by 4%, would that give an 8%
increased chance of rupture? Hope I'm making sense.
Thank you,
Heather

Posted By n/a on 02/20/2007 7:08 PM
Henci,
We are still TTC at this point, but, I have a question. You
mentioned in your post that the recomendation differs for rupture
and dehiscence. Can you point me to where I can read what they say?
I have been doing a lot of reading and joined an ican group
online, these things have helped me clear my mind so much. I have
will try to HBAC if I can find a provider. I felt so much stress
just thinking about going in to another hospital. However, if it is
recomened by a provider I trust(someone who supports VBAC and
normal birth) that I should plan another c/s I will give it serious
thought. I am also wondering if mulitple induction drugs are given
do the risks that go along with them go up accordingly. What I mean
is say a prostaglandin gel increases rupture risk by 4%- don't have
numbers in front of me- and pit also by 4%, would that give an 8%
increased chance of rupture? Hope I'm making sense.
Thank you,
Heather

I can't think of a specific reference on the dehiscence vs. scar
rupture recommendation. I just know that it is pretty much
universally recommended that if the scar has come completely
unzipped in a prior VBAC labor, a planned repeat c/sec is
recommended. I also know that I have read that a dehiscence, a
small, harmless "window" in the scar, is not believed to
pose excess risk in subsequent labors.

As for the use of cervical ripening/induction agents, several
studies have found increases in scar rupture with various
agents and combinations of agents, but it isn't as straightforward
as adding the increased risk of individual agents together. The
degree of increased risk--and some studies do not find any--depends
on the characteristics of the women in the study, what agents were
used, in what combinations, and at what dosages. No two studies are
alike on that score.

I still think your best bet is to review your medical records with
an obstetrician who encourages VBAC. Now that you are in contact
with ICAN, hopefully you can find someone through their network.
Considering how important this decision is, it may be worthwhile to
travel if such a person is not available in your community.

I am not aware of any studies specifically on labor with a small
window in the scar. What we have is indirect evidence: a number of
papers and reviews from the 1980s found about the same percentage
of women who have planned repeat cesarean prior to labor have an
opening in the scar at the time of the surgery as have a scar
separation during a VBAC labor. This implies that women must be
laboring with these windows and not having a problem with them
otherwise rates would be much lower in women having planned
surgery. I could provide the citations for these papers, but your
strongest argument is that the exact degree of risk or lack of risk
is irrelevant. You should have the right to refuse surgery even if
your doctor deems it inadvisable and still receive medical care
just as it would be if you were not pregnant. That being
said, because there may be a greater risk, it would probably
be better to labor in a hospital that can perform an urgent
cesarean at any time of the night or day and to avoid inducing
labor with oxytocin or prostaglandins or augmenting labor with
oxytocin because these agents increase the risk of scar rupture. It
would also be better to avoid an epidural because it increases need
for labor augmentation.

I have a 1992
study of dehiscence, which the authors defined as "silent
separation of a scar incidentaly diagnosed at laparotomy or vaginal
examination with no fetal or maternal compromise" (p. 540). One
woman of 475 (2 per 1000) having a VBAC had a dehiscence detected
whereas 19 of 924 (21 per 1000) had one found incidentally at
cesarean surgery. I also have a 1989
study distinguishing between dehiscence, which authors defined
as "separation of the uterine scar with unruptured membranes" (p.
570), and scar rupture. Six of 1008 women (6 per 1000) had a scar
rupture, but 44 of 1105 (40 per 1000) had a dehiscence discovered
at either repeat elective cesarean or VBAC ending in cesarean.

I have a related question. I was "diagnosed" with a thin
LUS during a term (39w) repeat cesarean due to double footling
breech presentations in both twins. Twin B flipped breech at
33 weeks; twin A at 37 weeks. Argh!

My Baby A initiated labor by violently kicking and breaking her
amniotic sac. Labor contrax began 15 minutes later; the
cesarean took place about 3 hours after that.

I'm planning for a VBA2C (22 mo. intrapartum interval; age 38;
healthy; BMI under 30) and been urged to find an OB. Local
docs are 'behind the times' when it comes to revising their VBAC
practices and finding a VBAmC supporter is next to
impossible. VBA2C is still in the SOP for homebirth midwives
in my state.

I interviewed an OB last week who agreed to take me if I sign an
AMA waiver. The first words out of his mouth before I even
gave him my background were "DON'T DO IT!" Awesome.

Anyway, he's certain that if I had a thin LUS at term with the
twins, that my scar is weaker and more likely to rupture. I
was under the impression that 'back in the day' when docs were
palpating VBAC scars, they would leave dehiscences alone because
the uterus would heal itself. What is your impression of
"thin LUS" (parchment paper) and implications for my upcoming
plans. Other docs I've talked too about this in the past said
there's really no way to "know" what it means.

Whoever told you there is no way to know what implications a
thin scar has for a planned VBAC was on the money. Here are
the problems with sonographic measurements:

Studies used scar "defect" as their outcome. "Defect" includes
harmless dehiscences, which we know (see previous posts in this
thread) occur more frequently than scar ruptures. In fact, in all
but one study, the scar evaluation was made at repeat cesarean,
which means we don't know how many VBAC women had an
uneventful vaginal birth despite having a "defect."

While thicker lower uterine segments are less likely to develop
defects in labor, i.e. good negative predictability, the positive
predictability of thinner ones for defects isn't that great.
Furthermore, a pooled analysis of multiple studies could not
establish a useful cutoff point because of variability among
studies.

The likelihood of scar rupture is influenced by other
modifiable factors such as labor induction, oxytocin augmentation
of contractions, single- vs. double-layer uterine closure.
Investigators do not account for these in their studies of LUS
thickness, which means we have no idea of the isolated effect of
thickness in an otherwise optimally treated population.

Accuracy of measurement depends on the skill and experience of
the ultrasonographer.

Meanwhile, any discussion of planned VBAC vs. planned elective
repeat cesarean surgery should take into account the escalating
risks of serious maternal and perinatal complications with scar
accumulation.

I just wanted to give a little update. I did give birth
vaginally earlier this week. My uterus did its job in spite
of having multiple scars and a previous diagnosis of 'thin lower
uterine segment.' Hopefully women with this diagnosis will
find some comfort in reading this.

I am looking for a second opinion. I am 35yo, FTM,
approximately 33weeks. I have been seeing a group of midwives
since the beginning of this pregnancy and planned for a natural,
unmedicated L&D. In 2008, I underwent a myomectomy to
remove multiple uterine fibroids. I provided this information
at my first prenatal appointment but the post operative report was
not reviewed until this week during a routine 2-week check
up. The midwife had some concerns and had me schedule an
appointment the following day with one of the physicians. I
was told that I have a classical uterine incision and because of
the risk of dehiscence, I have to schedule a ceasarean at 39
weeks. My preliminary findings give me no assurance that I
have any other option. This is devastating news for me as I
may not conceive again. I understand the type of incision I
have bears a 4% chance of uterine rupture or dehiscence, but what
about the other 96%? Thank you in advance for your
response.

I wrote a post in this
thread that provides the best information I could find on the
risks of scar rupture with a vertical, AKA, "classical" uterine
incision. As you can see, it is lower than commonly believed,
although it is probably still higher than it would be with a prior
transverse uterine incision. I would assume that the same odds
would apply to an incision made for fibroid surgery. In that same
post, I also wrote about every patient's right to refuse surgery, a
right that is not suspended by pregnancy, and I provided a
link to a fact sheet on the risks of cesarean surgery, which
further strengthens the argument that the choice should be
yours. As you have discovered, though--"I have to schedule a
cesarean at 39 weeks"--all too often, that right is not honored by
obstetricians. I wish I could do more to assist you, but the best I
can offer is to affirm that your preference for planning
vaginal birth is reasonable, but if you cannot convince your
doctors to respect your right to do so, see if you can find another
doctor who will.

It sounds like you have experienced a personal loss or
someone you know has experienced a loss as a result of planned
VBAC. If this is the case, you have my deepest sympathy. However, I
am bound to point out that elective repeat cesarean surgery is not
risk free. In fact, the odds of a woman dying as a result of
elective repeat surgery are roughly the same as the odds of a baby
dying as a result of a scar rupture in a VBAC labor. Accumulating
cesarean surgeries also poses escaling risks to future babies
whereas a VBAC will almost always be followed by future
uneventful VBACs. No one can predict the future, but the odds
for most women favor planning VBAC.

~ Henci

All Times America/New_York

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